Failure to Immediately Notify Physician After Resident Fall with Injury
Penalty
Summary
A deficiency occurred when the facility failed to ensure immediate physician notification following a resident's change in condition after an unwitnessed fall. The resident, who had a history of coronary artery disease, hydronephrosis, renal insufficiency, anxiety, depression, atrial fibrillation, and cardiomyopathy, was found on the floor next to her bed after reportedly rolling out. She sustained an open hematoma to the right lower leg, a knot on the back of her head, and a small red area to the right eyebrow. The resident was alert, complained of a headache, and was given Tylenol, which relieved her pain. Neurological checks were initiated and were negative, and the resident was moved to the nursing station for monitoring. The staff notified the family by telephone and the unit manager by text message. However, the attending physician was notified only via fax, and there was no direct verbal communication. The physician later stated he was not contacted about the fall and was unaware of the fax, emphasizing that the usual protocol required a phone call for injuries, especially those involving head trauma. The LPN involved acknowledged that after receiving no response to the fax, he should have called the physician directly but did not do so. Facility policy required prompt notification of the resident, physician, and representative in the event of a change in condition. The failure to provide immediate verbal notification to the physician, particularly in the context of an injury with head trauma, constituted a deviation from established protocols and resulted in the cited deficiency.